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Ankle Fracture

What Is An Ankle Fracture?

Please see foot & ankle anatomy for more information about the ankle joint.

As the name suggests this is a fracture involving the ankle joint. Fractures of the ankle are a common sports injury.

A “Fracture”, “break”, and “crack” are often used to describe an injury to a bone. Contrary to what most people think, they all mean the same thing. A fracture is a complete or incomplete break in a bone resulting from the application of excessive force. 

There are many different types of ankle fracture, and as a result there are many different ways of classifying and describing ankle fractures.

We will use two systems, one based on anatomy to describe the location of the fracture, the other based on stability which helps guide management of the injury.

The anatomical descriptive classification outlines the part(s) of the ankle joint injured:

  • Lateral malleolus fracture
  • Medial malleolus fracture
  • Posterior malleous fracture
  • Bimalleolar fracture (Fibular and medial sided injury – medial malleolus and/or deltoid ligament)
  • Trimalleolar (lateral, posterior and medial malleolus)
  • Fracture dislocations
  • Syndesmotic injury
    • This may occur with or without an associated fracture
A - lateral x-ray of the ankle best demonstrates the posterior malleolus B - the AP (front to back) x-ray best demonstrates the medial and lateral malleoli

A – lateral x-ray of the ankle best demonstrates the posterior malleolus B – the AP (front to back) x-ray best demonstrates the medial and lateral malleoli

Ankle fractures can also be classified as:

  • Stable 
  • Unstable

We can define stability as the ability of a body structure to withstand physiological load without deformation and displacement.

Stable injuries can be managed non-operatively while unstable fractures require surgical fixation.

  • Lateral malleolus fracture – usually stable
  • Medial malleolus fracture – usually unstable
  • Posterior malleous fracture – usually unstable
  • Bimalleolar fracture – always unstable
  • Trimalleolar – always unstable
  • Fracture dislocations – always unstable
  • Syndesmotic injury – usually unstable

 

A - isolated stable avulsion fibular fracture B - stable fibular fracture C - medial malleolar fracture D - bimalleolar fracture

A – isolated stable avulsion fibular fracture B – stable fibular fracture C – medial malleolar fracture D – bimalleolar fracture

What Can Cause It?

The exact mechanism of injury differs according to which anatomical area the fracture has occurred in.

The following can cause an ankle fracture:

  • Twisting and turning force 
  • Rolling in or rolling out of ankle 
  • Tripping or fall
  • Direct blow (for example a tackle)
  • High energy (road traffic collision)
  • Stress fracture

What Are The Symptoms?

Symptoms can vary from patient to patient and depend on the severity of the underlying fracture.

Common symptoms and signs following an ankle fracture include:

  • Immediate and severe pain
  • Inability or difficulty to weight bear
  • Swelling (can be significant and involve the whole leg)
  • Blisters
  • Bruising
  • Tenderness to touch
  • Deformity (seen in dislocations)

What Investigations May Be Required?

Most fractures of the ankle can be identified on an x-ray (radiographs).

Radiographs provide the following information regarding the fracture:

  • Location of the break(s)
  • Number of bones involved
  • Whether it is a complete or incomplete fracture
  • Presence of comminution (multi fragmentary)
  • Whether it is stable or unstable (displacement)
  • Dislocation or subluxation of the joint
  • Whether the fracture extends into the joint (intra-articular)
Radiograph (x-ray) demonstrating a fracture of the lateral and posterior malleolus

Radiograph (x-ray) demonstrating a fracture of the lateral and posterior malleolus

A - normal ankle x-ray B - unstable ankle fracture, note the increased gap in the inner aspect of the ankle due to rupture of the deep deltoid, resulting in the talus moving outwards, the lateral malleolus is also broken

A – normal ankle x-ray B – unstable ankle fracture, note the increased gap in the inner aspect of the ankle due to rupture of the deep deltoid, resulting in the talus moving outwards, the lateral malleolus is also broken


CT is not usually required to make the diagnosis in acute setting for straight forward ankle fractures.

CT maybe used for imaging a particularly complex ankle fracture pattern and for pre-operative planning purposes.

It may also be considered in the setting of a delayed union or non-union.

CT demonstrating subluxation of the ankle joint with posterior malleolar fracture fragment

CT demonstrating subluxation of the ankle joint with posterior malleolar fracture fragment

>3D CT reconstruction of a complex ankle fracture A - fibular fracture B - posterior malleolar fragment C - large medial malleolar fragment

3D CT reconstruction of a complex ankle fracture A – fibular fracture B – posterior malleolar fragment C – large medial malleolar fragment


MRI is not usually required to make the diagnosis in acute setting.

MRI provide high resolution images of both bones and soft tissues, such as  cartilage and ligaments. In select cases it may be necessary to request an MRI to visualise ligaments and cartilage damaged in an ankle fracture.

Can The Problem Get Worse?

The majority of people with an ankle fracture have no long term complications.

Patients who have stable fractures are very unlikely to develop further problems such as arthritis.

Unstable fractures and fractures extending into the joint surface that damage the cartilage are likely to develop degenerative changes (arthritis) in the ankle joint.

An operation that restores anatomy and provides rigid fixation can minimise these risks. With severe injuries such as open fractures (break in the skin with bone exposed), fracture dislocations and high energy injury resulting in significant joint (cartilage) damage, despite surgery there is a significant risk of developing post traumatic arthritis. See Ankle arthritis for further information.

A - A normal ankle x-ray, note the even joint surface B - am x-ray of post traumatic in a patient with previous trimalleolar ankle fracture C - An x-ray of post traumatic ankle arthritic in a patient with a medial malleolar fracture

A – Normal ankle x-ray, note the even joint surface B – post traumatic ankle arthritis in a patient with previous trimalleolar ankle fracture C – Post traumatic ankle arthritis in a patient with a medial malleolar fracture

Non-Operative Treatment Options

Many ankle fractures can be treated non-operatively.

If the fracture configuration is suitable and the ankle felt to be stable then this will be the treatment of choice.

A weight bearing ankle or gravity stress view is usually required to make sure that the ankle is indeed stable.

A - x-ray of the ankle demonstrating a fracture of the lateral malleolus, B - on weight bearing views there is no displacement of the bones indicating this is a stable fracture and can be managed non-operatively

A – x-ray of the ankle demonstrating a fracture of the lateral malleolus B – on weight bearing views there is no displacement of the bones indicating this is a stable fracture and can be managed non-operatively

While the fracture heals, which may be anywhere form 6 weeks to 6 months, the ankle needs to be protected.

Non-operative treatment would typically comprise of one of the following depending on individual patient and fracture characteristics for at least 6 weeks:

  • Non weight bearing in cast
  • Weight bearing in cast 
  • Weight bearing in functional boot
  • Weight bearing in ankle brace

An x-ray would be repeated at the 6 week clinic appointment to assess healing.

Depending on the radiological and clinical findings at the 6 week appointment, further protection may be required.

If the fracture has healed, a referral to physiotherapy will be advisable in most cases.

Operative Treatment Options

Surgical management is reserved for patients who have an unstable fracture configuration, patients who require early return to sports and function or have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

A variety of surgical options exist which need to be tailored to the individual and the actual fracture. Mr Malik, Consultant Orthopaedic Foot and Ankle Surgeon has over 15 years experience of fixing ankle fractures and has undertaken hundreds of ankle fracture procedures with excellent results.

Ankle fractures are best fixed once the soft tissue swelling has subsided. It may be necessary to delay surgery for a week or so until the swelling has gone down. Operating while the foot is too swollen increases the risk of wound breakdown and infection. There is usually a window of up to 2 weeks to fix an ankle fracture, before the body starts to heal the fracture, which then makes it more difficult.


Lateral malleolus fracture

This operation has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves reducing the fracture (restoring the anatomy), and then fixing the fibular bone with screws and a plate.

The operation is usually carried out through one incisions on the outer aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.

A - an x-ray of lateral malleoli fracture, B - an x-ray showing a fixed with plate and screws with anatomical reduction

A – an x-ray of lateral malleoli fracture, B – an x-ray showing a fixed with plate and screws with anatomical reduction


Medial malleolus fracture

This operation has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves reducing the fracture (restoring the anatomy), and then fixing the medial malleolus typically with one or two screws and rarely a plate.

The operation is usually carried out through one incisions on the inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.

A - an x-ray demonstrating isolated medial malleolus fracture (white circle), B -an x-ray showing a successful fracture fixation with two screws

A – an x-ray demonstrating isolated medial malleolus fracture (white circle), B – an x-ray showing a successful fracture fixation with two screws


Posterior malleous fracture

Surgery involves reducing the fracture (restoring the anatomy), and then fixing the posterior malleolus typically with screws and a plate.

The operation is usually carried out through an incision at the back of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.


Bimalleolar fracture 

This operation has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves fixing the fibular bone with screws and a plate and the medial side of the ankle with screws (rarely a plate).

The operation is usually carried out through two incisions on the outer and inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.


Trimalleolar 

This operation has good outcomes in terms of pain relief and return to activities of daily living. Due to the nature of the injury there is however increased risk of developing post traumatic ankle arthritis even despite surgery.

It involves fixing the fibular bone with screws and a plate and the medial side of the ankle with screws (rarely a plate), and the posterior malleolus with screws and a plate.

The operation is usually carried out through two incisions on the posterior and inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require at least one night stay in hospital.

A - an x-ray showing a normal lateral ankle, B - an x-ray showing Trimalleolar ankle fracture, C - an x-ray after surgical fixation the ankle joint has been anatomically restored and the fractures fixed with plates and screws

A – an x-ray showing a normal lateral ankle, B – an x-ray showing Trimalleolar ankle fracture, C – an x-ray after surgical fixation the ankle joint has been anatomically restored and the fractures fixed with plates and screws


Fracture dislocations

This operation has good outcomes in terms of pain relief and return to activities of daily living in the short term. Due to the nature of the injury there is however increased risk of developing post traumatic ankle arthritis even despite surgery in the mid to long term.

The details of the operation depend on the specifics of the fracture configuration.

The operation is usually carried out through two incisions on the posterior and inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require at least one night stay in hospital.

A - x-ray of a normal ankle, B - an x-ray of an open fracture dislocation of the ankle with contaminated wound. This patient is at high risk of developing osteomyelitis and post traumatic arthritis

A – x-ray of a normal ankle, B – an x-ray of an open fracture dislocation of the ankle with contaminated wound, this patient is at high risk of developing osteomyelitis and post traumatic ankle arthritis, note this patient had a severe syndesmotic injury – see below


Syndesmotic injury

These are high energy injuries that rupture some or all of the syndesmotic ligaments. Read about the anatomy of the syndesmotic ligaments here.

The syndesmosis binds the fibula and tibia together. Injury to this ligament complex can be either a sprain or complete rupture resulting in gross instability of the ankle.

A syndesmotic injury can be purely ligamentous or associated with an ankle fracture.

The operations to repair the syndesmosis with or without ankle fracture fixation has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves reducing the fracture (restoring the anatomy )when present, and then fixing the syndesmosis.

The operation is usually carried out through more than one incision. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.

X-rays of the ankle demonstrating A and B - bimalleolar ankle fracture with syndesmotic injury resulting in ankle dislocation and gross instability, C and D post operative x-rays demonstrating anatomical fracture reduction, rigid fixation and restoration of the normal joint

X-rays of the ankle demonstrating A and B – bimalleolar ankle fracture with syndesmotic injury resulting in ankle dislocation and gross instability, C and D post operative x-rays demonstrating anatomical fracture reduction, rigid fixation and restoration of the normal joint

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment of ankle fractures include:

  • Worsening pain
  • Increased stiffness
  • Chronic swelling
  • Skin breakdown and infection
  • Non union (bones do not heal)
  • Delayed union (bones take longer to heal)
  • Compartment syndrome
  • Post traumatic arthritis
  • Deformity (change of foot and ankle shape)
  • Instability (weakness in the joints)
  • Adjacent joint disease
  • Pain elsewhere, for example in the knee, hip or lower back (due to abnormal gait and compensatory mechanisms)
X-ray of a fracture dislocation of an ankle. Note how the skin is being stretched over the sharp edge of bone (blue arrow), left untreated the skin will breakdown and the patient will be at serious risk of developing osteomyelitis and ankle arthritis

X-ray of a fracture dislocation of an ankle, note how the skin is being stretched over the sharp edge of bone (blue arrow), left untreated the skin will breakdown and the patient will be at serious risk of developing osteomyelitis and ankle arthritis


Complications can occur as with any type of surgery. Please see Foot and Ankle Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • Failure to fully correct deformity (particularly if longstanding deformity)
  • Need for further surgery (revision or further treatment)
  • Persistent pain
  • Complex regional pain syndrome
  • Nerve injury
  • Wound healing problems

Potential specific complications of ankle fracture fixation include the same as those of non-operative management and:

  • Need for metalwork or hardware removal such as plates and screws
  • Loss of fixation requiring further surgery
  • Worsening pain
  • Increased stiffness
  • Chronic swelling
  • Skin breakdown and infection
  • Non union (bones do not heal)
  • Delayed union (bones take longer to heal)
  • Compartment syndrome
  • Post traumatic arthritis
  • Deformity (change of foot and ankle shape)
  • Instability (weakness in the joints)
  • Adjacent joint disease
  • Pain elsewhere, for example in the knee, hip or lower back (due to abnormal gait and compensatory mechanisms)

 

Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.

Picture of a backslab

A picture of a backslab

Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.

You will be non weight bearing for approximately 6 to 8 weeks based on the ankle fracture configuration. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

A picture demonstrating high elevation after a foot operation

A picture demonstrating high elevation after a foot operation

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your toes and knee at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.

You will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.


Six weeks post operatively

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.

Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.

If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.


Three months post operatively

Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.

FAQs

How long does the operation take?

This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.

Am ankle fracture fixation can take up to 90 minutes.


When can I drive?

Depends on the side operated on and whether you drive an automatic car. If the car is manual then regardless of the side operated on it will be roughly 3 months post surgery. If you drive an automatic and the left foot has been operated on then it will be roughly 4 weeks before you can drive short distances.

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.


When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.


What should the final outcome be?

Excellent pain relief and return to full activities of daily living in the majority of patients.

A Patient's Experience - Lisa King November 2016

Why did you decide to have your ankle operated on?

Following a fall from my horse I visited A&E where I was diagnosed with a left ankle fracture. Because I had had a spiral fracture of my left leg twenty years prior, I had a number of metal pins and a rod in place. Consequently the hospital consultant recommended I underwent an operation to repair my ankle. I decided to get a second opinion and scoured the internet for names of consultants specialising in ankle injuries. Having read Mr Malik’s website, along with his testimonials, I felt he was the obvious choice.

I spoke to his secretary and was given an appointment for his clinic that same day. After an initial examination he immediately arranged for me to have further X rays and a CT scan which revealed my injury was far more extensive than originally diagnosed. My condition was medial malleolar fracture but in addition Mr Malik diagnosed a posterior malleolar fracture, a syndesmotic injury and lateral ankle ligament injury. My consultation was meant to be a twenty minute duration but Mr Malik spent nearly two hours with me making sure he had all the information he needed for a complete diagnosis. He arranged for me to have an operation within two days. I felt extremely reassured by Mr Malik’s thoroughness, his passion for his profession and his obvious levels of expertise in his field.

What were your concerns before the operation?

I didn’t have any concerns about the operation. Mr Malik chatted to me before I went to theatre and explained the exact procedure I was going to have. He also explained how my pain would be managed.

What was your experience of the operation and the recovery?

The operation went to plan. It was a two hour procedure and I felt very groggy for the next twenty-four hours after. I decided not to go home the next day as my operation hadn’t finished until very late the night before. Looking back this was the right decision as being in hospital one more day made me feel more confident my pain could continue to be managed whilst giving me the time to regain some strength.

My recovery was long, very long! It was a seven week period before I was fully weight bearing. I had to spend 55 minutes of every hour with my leg elevated. I managed well with the crutches for the small amount of time I was allowed to be on them. I made good use of a rucksack to take light items from “A to B” and I overcame the challenge of carrying hot drinks by making up a flask. A friend lent me a shower chair which was a god send! I was in plaster for two weeks following the operation and a boot for the next five. The boot was more comfortable but sleeping in both was challenging.

What was the most challenging part of having your ankle operated on?

The seven week non weight bearing period was definitely the most difficult. I have a daughter, three horses, two dogs and a husband that works very long hours, so I needed to organise a lot of help to care for my family. It was very frustrating not to be able to do things for them. I really missed the physical exercise and the mental wellbeing it provides.

What advice would you give future patients?

Be prepared. Make all the arrangements for help and support for you and if appropriate your family, before the operation. Once home have all the things you need each day close to hand. Make sure you have a suitable chair or sofa which allows you to lie or sit with your ankle in an appropriate position, located in the main hub of your home. It will help to give you a sense of normality.  Accept you will not be able to resume life as before during your recovery period and welcome all offers of help from friends and family. Remind yourself that your immobility is for just a short period of time in your life and as long as you follow Mr Malik’s instructions you will be one step closer to a full recovery with each passing day.

Lisa King November 2016

 

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